GW1-2023-02171_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
K� 14.WATER ZONES
Will Contractor Name FROM
�j FROM TO DESCRIPTION
g '0-ft. 1 L� ft
� `-'
NC Well Contractor Certification Number ft. ft
15.OUTER CASING for multi-cased wells LINER Of a licable
Aqua Drill, Inc. FROM To OR DIAMETER THICKNESS .MATERIAL
Company Name U ft. 9 ft- in. )�'Z
16.INNER CASING OR TUBING igenthernial closed-loo
2.Well Construction Permit CI -6�YIPga -i_,`; 2 ci`i<_ FROM TO DIAMETER THICKNESS nrATERiAL
List all applicable well construction permits Ae.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use)- ft. & in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
�MunicipaMblic ft ft.
-Geothermal(Heating/Cooling Supply) IMResidential Water Supply(single) _P
ft. ft, in.
IndustrialfCommercial DResidential Water Supply(shared)
18.GROUT
hri ation FROM TO MATERIALEMPLACEMENT METHOD&AM1iOUN•f
-
Non-Water Supply Well: Q ft. 0 ft.
Monitoring Recovery ft. ft
Injection Well:
ft. ft.A uifer Recharge oGroundwaterRemediation Aquifer Storage and Recov 19.SAND/GRAVEL PACK rf a licable
cry EISalinityBarrier FROM TO I r6 ERIAL EMPLACEMENT MUROD
Aquifer Test IDStotmwater Drainage ft. ft.
Experimental Technology oSubsidence Control ft ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness solUrnck a nln//s�1;ze do)
�ry �
4.Date Well(s)Completed: r�Cl 7-1 - ell ID#L 6 ft- C ft �1 d
5a Well Location: - 5—It. j�t 71uC G fZ►?Y�i` �'
ft. ft
Facility/Owner Name Facility lD#(ifapplicable) ft. %
5�� 1.I I/� T ft. I -
Ph sical Addr b k r. w•d
Y css,City,and Zip -7 Its ft.
21.REMARKS V 1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: am:
(ifwell field,one lattlong is sufficient) 22.Certification:
N W z1v
6.Is(are)the wellot§rermanent or IOTemporary Stgnature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constricted in accordance
7.Is this a repair to an existing well: [)Yes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction it formation and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1'GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
9SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100)
construction to the following:
10.Static water level below top of easing: 5-0 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing rise"+/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (YJ (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: //Z (4ha t f above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) r construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
` 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: S 1`C' -1' 24c.For Water Supply&.Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 'Amount:_ ) completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

GU.ILFORD COUNTY DEPARTMENT OF PUBLIC BEALTII
Division of Environmental Health,Water Quality Unit
t 400 W. Market St.,Suite 300, Greensboro,NC 27401
R@P3hfp OrAbandanment
Address of Well: 32 JJ b ta- - 546tC-<-d-, e N
r�
��LA111'UDE 3_
Well Permit NumberJ� z- C 9 -t,}y.j i j IZ -G�2 C4�6 LONGITUDE
Well Contractor Company:
. ��f�....,� � Completion Date:��. ' �7-
Total Well Depth:. 2 ft. Well Yield.J O gpin Static dilater Level: -0 ft,
®enter Cuing Material:1;DT2_2 IE`�r��tu®�n Leg
Casing Diameter: in. Casing Depth: ft. De th
--�--- P Description
From: Depth
To: _ft, l�r�'.d L_) .I
1 mer Caan ng Material: From:-L_ft.To: �S` ft.. 5 i4Jyc� 1Zc�
Casing Diameter: in. Casing Depth: ft. ]From ft.To:.2?S-'t. (�;z iv }
From: ft.To: ft.
Grout From: ft. To: &
Depth Material Method From: ft.To:
From: ft.To:�_ft. ft.
From, To-._ft. t' -- -- From: ft.To: ft.
ft. From: ft.To: ft.
From.--ft.To-___ft.
From:
Depth:
eer Production Zones
ft. :ft. ft: ft• ft:
Yield: _1Q gpm m ft- ft.
gPm ;pm gpm gpm gpm
Method of Repair:
Method of Abandonment:
I hereby certify that this well was constructed,repaired,or abandoned according to the Guilford County Well
Rules id effect on this
date and that a copy of this record has been provided to the well owner.
Well Contractor:l�� '
���' Certification#:2L26 -?-7 Dater
Record aq PUMP gnabdpadan
Pump Instillation Company:
-----� Completion Date:__a 1 .3
Pump Depth: r ft.. Static Water Level: 1-4 V ft.
Pump Brand: �1 VW �, 'r,� , j/ �t7--� primp Size and Rating: �I� 11 /�
A gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on this date d that a cop of this record has been provided to the well owner.
Well Contractor: J� Certification �
Date:
Revised:January 1,2009